Read ERA 835s from Payors

When payors adjudicate a claim, they send your practice an Electronic Remittance Advice (ERA), also known as an 835 file.

Your PCC system receives these ERAs. You can automatically post most payments and adjustments, and then review only those claim responses that require manual attention, such as denials, reversal, rejections, and unusual adjustments.

Use the Electronic Remittance Advice tool in PCC EHR to read any ERA on your system and review the adjudication for a claim.

Video: Watch Read ERA 835s from Payors to learn more.

Open the Electronic Remittance Advice Tool and Find an ERA

Open the Electronic Remittance Advice tool to review payments and adjustments sent to your practice electronically.

Payers send adjudication to your PCC system as ERAs, also known as 835 files. For each ERA, you can see the Remittance date, when the ERA was processed, the payor, the complete check number, and the total amount of the check associated with the ERA.

You can filter the list of ERAs by whether they are Processed, Unprocessed, or Deleted.

You can also search your practice’s ERAs. For example, you could look for the ERA pertaining to a specific check number or review all ERAs from a specific payor.

Review ERA Details and Processing Summary

Double-click on an ERA to review its contents.

At the top, PCC indicates whether the ERA has been processed and by whom.

Next, summary information about the ERA appears in three or four sections.

  • ERA: The ERA section at the top describes the basic information about the ERA, including the remittance date, payor, complete check number, and amount.

  • Autopost Processing Summary: If your practice has processed the ERA, the next section describes the results, including total amounts and number of claims for payments, adjustments, and exceptions. You can also see how many claims on the ERA were adjudicated as being the primary, secondary, etc. policy for the patient.

  • Payor: The Payor section includes details about the payor as found in the ERA 835 file, including their provided adjudication and remittance dates, the complete check number, amount, and electronic banking information. The payor may include various types of contact information on an ERA. For example, they may include optional additional contact details which will appear as “Tech Email” and “Tech Phone”.

  • Payee: The Payee section includes information about the entity receiving the ERA and the payment. Typically, this is your practice. This section will display the practice name, address, and banking information as reported by the payor.

Review Specific Claim Response Details

Below the summary sections, PCC displays detailed payment and adjustment information for each claim referenced on the ERA.

Claim Identifiers

For each claim on the ERA, you can see the patient’s name, PCC ID, Payor Claim Control Number, patient’s insurance ID, and (if the ERA has been processed) whether it was processed as being the patient’s primary, secondary, etc. policy.

  • PCC ID: The PCC ID is a combination of the patient PCC number, a space, and the claim ID number generated on your system when you processed claims.

  • Payor Claim Control Number: The Payor Claim Control Number, sometimes called the Internal Control Number (ICN), is issued by the payor to identify the claim. It’s common for payors to require the Payor Claim Control Number when you submit a corrected claim.

  • Insurance ID: The Insurance ID is the patient policy insurance number, found on the patient’s insurance card and stored with the policy on the patient’s record.

  • Payments and Adjustments

    Underneath the claim identifiers, a table displays detailed information about each charge on the claim.

    The table and the details beneath explain the payer’s adjudication.

    • Charges and Payment and Adjustment Amounts: For each charge, you can see columns for the date of service and procedure code followed by columns for the amounts of the charge, deductible, copay, personal responsibility, total personal due, contractual adjustment, other adjustment, and payment as reported by the payor on the ERA.

    • Downcoding: If the payor changed a procedure code for a charge, a special “Submitted if Different” column will appear so you can compare the code you submitted on the claim to the code being reported by the payor.

    • CARC, Group, and RARC: When a payer includes CARC, Group, and RARC information for a charge, you can see it inline in the table. For definitions, you can expand the Key below each claim.

    • CORE Business Scenarios: When PCC identifies that a payor’s response matches a CORE business scenario, you can see a description underneath the table. These scenarios can help you understand the payor’s response more quickly. For more information, you can read about the CORE Code Combinations as explained in the CAQH operating rules.

    • Exception Reasons: When the ERA has been processed, and the payor’s response to the claim could not be automatically posted, PCC displays the Exception Reason, which defines why the response requires your manual attention.

    Work on Claim Responses that May Require Additional Attention

    Sometimes your PCC system cannot post the payor’s response automatically, creating a “Payment Exception”, which you must address manually. You may also want to work with claims with specific statuses from the payor, such as Reversals or Denials. You can use the details on an ERA, including the identified payment exception reasons, to understand what actions to take next.

    Use the Display filter to view encounters with an exception.

    Use the Exceptions filter to view encounters that have specific exceptions.

    Use the Payor Processing Status filter to view encounters with specific statuses, such as Reversals or Denials.

    When you apply a filter, the ERA will change to display only those claims that match your selection.

    You can optionally print the filtered ERA so you can track and work on the claims manually.

    For each claim with a payment exception, you might decide to contact the payor, post the payments manually, or change the responsible party for charges and generate a new claim. You can learn more and review a list of all payment exception reasons in the Post Insurance Payments article.

    When you post the response details manually, you can bring up the encounter charges automatically by entering the Claim ID, which is the second part of the PCC ID on the ERA.

    The Manual Report?: Prior to PCC 9.9, your billers may have automatically posted payments and worked on posting exceptions (the “Manual Report”) on the screen in Practice Management. In PCC 9.9, they can use the Electronic Remittance Advice tool and filter for Posting Exceptions as shown above to review the same details with greater clarity and ease-of-use.

    Delete an ERA

    If a payor sends your practice an ERA that is not related to your patients and your billed charges, you can delete it.

    Double-click on an ERA in the Electronic Remittance Advice tool to open it.

    Next, click “Delete” at the bottom of the window.

    PCC will change the ERA’s status to “Deleted” and log the user and time of deletion.

    To retrieve an ERA that was deleted by mistake, first set the Status filter at the bottom of the window to display all deleted ERAs.

    You can then open a deleted ERA and click “Undelete” to revert its status.

    The ERA Reports Tool in the Practice Management Interface

    Prior to 2024, billers used the ERA Reports tool to review payor adjudication responses.

    Run the ERA Reports Program

    Run the ERA Reports program from the Insurance Billing & Collections window in Practice Management. Your practice’s custom windows and program lists may be different.

    PCC translates ERA 835 files from payers into check files. For each check file, you can see the date the carrier sent the information, the payor’s name, the check number (or reference number), the amount of the check, and the amount that has been autoposted, if any. All check files appear in ERA Reports, whether or not you have posted them yet.

    The most recent incoming information appears at the top. You can press Page Down and Page Up to review the list, press F4Jump to Date and enter a date to see any day, or press F5Search to search for a specific check number, carrier, or name.

    Review Full Reports

    Select any check file and press F3Full Report to read it.

    The full ERA check file will contain payments, adjustments, denial information, and other data from the payor.

    Note: The full ERA check file is not the original ERA file sent by the payor. PCC splits the original file into check files and formats them for easier reading. Use the ecsreports program to read all the contents of an ERA as a single file.

    Review Autoposted Reports

    After you run autopip to post the incoming remittance advice, you can use erareports to review the part of the check file that was autoposted.

    Select an ERA check file and press F2Auto Report to review autoposted items.

    Review Manual Reports

    After you run autopip, if there were any items that required direct attention, such as a payment that didn’t match the charge, an insurance takeback, or an incentive payment, they are collected in a “manual” report.

    Select the ERA check file and press F1Manual Report to read the items in the ERA that require manual attention.

    You can also review autoposted and manual reports from within the Autopost Insurance Payments (autopip) program.

    Navigate and Search an ERA

    On the screen, an ERA looks like this:

    You can you use the “Jump To” and “Search Pattern” function keys to find a patient name or ID, allowing you to quickly navigate to the encounter you need to review. Use the right and left arrow keys to view the parts of the report that extend off the screen.

    Press F4Send To... to print the ERA or email it.

    A printed ERA looks like this:

    See Both Codes When a Payer Responds to a Different Code

    When an insurance payor responds to a different code than the one you submitted, as is the case when they downcode or change the suffix, you can review the ERA to find out what codes were changed.

    In PCC EHR’s Electronic Remittance Advice tool:

    In PCC’s previous ERA viewer tool(s):

    Your PCC system interprets the ERA and can display both the SVC01 and SVC06 segments (adjudicated and submitted codes) for each charge. If the payer includes the information on their response, you’ll see both the code you submitted and the code they decided to respond to.

    By reviewing both columns, you can better understand what happened and take action to resolve the issue and then post the payments and adjustments.

    Note that payers sometimes reply to a charge by erroneously returning the NDC code instead of the CPT code you used on the claim! When that occurs, the NDC code will appear in the Submitted (if diff) column. Note also that if a payor fails to include SVC01 and SVC06 in the ERA, you will need to contact the payor to understand the discrepancy.

    • Last modified: June 27, 2024